MED_Oral_Patient_Reported.xml

<section>
	<templateId root="2.16.840.1.113883.10.20.22.2.1.1"/>
	<!-- Medication Section (entries required) -->
	<code code="10160-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="History of Medication Use"/>
	<title>MEDICATIONS</title>
	<text>
		<table border="1" width="100%">
			<thead>
				<tr>
					<th>Medication</th>
					<th>Instructions</th>
					<th>Dosage</th>
					<th>Effective Dates (start - stop)</th>
					<th>Status</th>
				</tr>
			</thead>
			<tbody>
				<tr ID="Medication_8">
					<td>
						<content ID="MedicationName_8" xmlns="urn:hl7-org:v3">ECHINACEA ANGUSTIFOLIA Extract</content>
					</td>
					<td>
						<content ID="MedicationSig_8" xmlns="urn:hl7-org:v3">Patient reports taking once daily</content>
					</td>
					<td>
						<content ID="MedicationDosage_8" xmlns="urn:hl7-org:v3">unknown</content>
					</td>
					<td>Apr-09-2014 - </td>
					<td>Active</td>
				</tr>
			</tbody>
		</table>
	</text>
	<entry typeCode="DRIV">
		<substanceAdministration classCode="SBADM" moodCode="EVN">
			<!-- This medication use case is a medication that the patient reports taking. If it has been already administered use moodCode = "EVN". -->
			<!-- If it is intended use "INT" or if ordered drug then use moodCode = "RQO" - Dependencies exist between moodCode, statusCode and effectiveTime  -->
			<templateId root="2.16.840.1.113883.10.20.22.4.16"/>
			<id root="2d359e3f-f2cb-437d-b004-9324d077be4e"/>
			<text>
				<!-- This reference refers to medication information in unstructured portion of section-->
				<reference value="#Medication_8"/>
			</text>
			<statusCode code="completed"/>
			<!-- This first effectiveTime shows that medication was added on April 9, 2014 which patient stopped taking on May 10-->
			<effectiveTime xsi:type="IVL_TS">
				<low value="20140409"/>
				<!-- The timing of last second of the day indicates the drug was taken on this day.-->
				<high value="20140510235959+0500"/>
			</effectiveTime>
			<!-- The second effectiveTime specifies dose frequency, which can be either a period (PIVL_TS) or event (EIVL_TS). -->
			<!-- InstituionSpecified = "false" is implied in ths omission of this attribute and means that it must be administered exactly once per day-->
			<!-- InstituionSpecified = "true" which is not default would mean that receiving institution has flexibility in dosing schedule-->
			<!-- Operator "A" means that this timing information is in addition to previous effectiveTime information provided-->
			<!-- The patient reports taking the medication once per day -->
			<effectiveTime xsi:type="PIVL_TS" operator="A">
				<period value="1" unit="d" />
			</effectiveTime>
			<routeCode code="C38288" codeSystem="2.16.840.1.113883.3.26.1.1" codeSystemName="NCI Thesaurus" displayName="Oral"/>
			<!-- The patient could not recall any specific dosage of this medication-->
			<!-- The nullFlavor of UNK is used since there is a dosage but it is unknown by C-CDA document author-->
			<doseQuantity nullFlavor="UNK"/>
			<consumable typeCode="CSM">
				<manufacturedProduct classCode="MANU">
					<!-- ** Medication information ** -->
					<templateId root="2.16.840.1.113883.10.20.22.4.23"/>
					<manufacturedMaterial classCode="MMAT" determinerCode="KIND">
						<!-- Medications should be specified at a level corresponding to prescription when possible -->
						<!-- Since this is an over-the-counter supplement and the patient could not describe brand or dose, ingredient is shown-->
						<code code="236121" codeSystem="2.16.840.1.113883.6.88" displayName="ECHINACEA ANGUSTIFOLIA Extract" codeSystemName="RxNorm">
							<originalText>
								<reference value="#MedicationName_8"/>
							</originalText>
						</code>
					</manufacturedMaterial>
				</manufacturedProduct>
			</consumable>
			<informant>
				<assignedEntity>
					<!-- This is a fictional OID and identifier for the patient. This should be adapted to local implementation -->
					<id root="2.16.840.1.113883.3.3208.101.2" extension="20130607100800-Patient1"/>
					<addr use="HP">
						<streetAddressLine>1111 StreetName St.</streetAddressLine>
						<city>Silver Spring</city>
						<state>MD</state>
						<postalCode>20901</postalCode>
						<country>US</country>
					</addr>
					<telecom value="tel:+1(301)111-1111" use="HP"/>
					<assignedPerson>
						<name>
							<given>Patient</given>
							<family>One</family>
						</name>
					</assignedPerson>
				</assignedEntity>
			</informant>
		</substanceAdministration>
	</entry>
</section>